A nurse is teaching a parent of a 4-month-old infant who has developmental dysplasia of the hip and is prescribed a Pavlik harness. Which of the following instructions on the use of a Pavlik harness should the nurse include in the teaching?
"Avoid massaging the skin under the straps."
"Use lotion on the skin under the harness."
"Adjust the harness straps weekly."
"Place the diaper under the straps."
The Correct Answer is D
A. "Avoid massaging the skin under the straps." Gentle massage is recommended to promote circulation and prevent skin breakdown.
B. "Use lotion on the skin under the harness." Lotion or powders should be avoided because they can cause skin irritation and breakdown.
C. "Adjust the harness straps weekly." Only the healthcare provider should adjust the straps to ensure proper hip positioning.
D. "Place the diaper under the straps." This helps keep the harness clean and dry, preventing skin irritation and breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","G"]
Explanation
A. Apply pressure to the puncture site following the procedure. Applying pressure helps prevent cerebrospinal fluid (CSF) leakage and reduces the risk of complications.
B. Limit the child's fluid intake following the procedure. Fluids should be encouraged to help replenish lost CSF and reduce the risk of post-lumbar puncture headache.
C. Position the child in a prone position during the procedure. The correct positioning for a lumbar puncture is the side-lying fetal position or sitting with the back curved forward to widen the space between the vertebrae.
D. Ensure the guardian has signed the consent form prior to the procedure. A lumbar puncture is an invasive procedure, so informed consent is required before proceeding.
E. Ensure the child voids prior to the procedure. Having the child empty their bladder before the procedure helps prevent discomfort and reduces the risk of bladder distention during positioning.
F. Insert an indwelling urinary catheter during the procedure. A urinary catheter is not necessary for a lumbar puncture unless there is another medical indication.
G. Monitor for paresthesia and tingling in extremities following the procedure. Paresthesia or tingling could indicate nerve irritation or injury, which requires prompt assessment and intervention.
Correct Answer is A
Explanation
A. "Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. "Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. "Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. "Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
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